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Ocular Disease Test 2 > Lens and Cataracts > Flashcards

Lens and Cataracts Flashcards

1
Q

Describe the anatomy of the lens

A

Cellular laminated avascular capsule
Inner nucleus is dense and water insoluble
Outer cortex is water soluble alpha/beta crystalline fibers
Anterior epithelial layer between cortex/capsule
Lens capsule is the basement membrane by epithelial cells

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2
Q

Describe the composition of the lens

A

Dehydrated structure 65% water and 35% solid
85% of solids - soluble alpha and beta crystalline fibers from the cortex; 13% are insoluble albuminoids, 2% gamma crystalline fibers in the nucleus

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3
Q

What is the purpose of the lens metabolism?

A

Clarity of lens

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4
Q

Briefly, talk about the biochemistry of ions and proteins in the lens

A

High potassium; low sodium

Proteins mostly responsible for whether or not lens remains clear

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5
Q

What is the definition of a cataract?

A

Any congenital or acquired opacity in the lens capsule or substance irrespective of the effect on vision
Can happen with aging and is common, can manifest as leukocoria

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6
Q

What are some congenital causes of cataracts?

A 
Developmenta
Maternal infection
Metabolic
Chromosomal (Down's)
Ocular maldevelopment (Peter's Anomaly)
Birth trauma
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7
Q

What are some causes of acquired cataracts?

A 
Senile
Endocrine (DM)
Trauma (Blunt, radiation)
Drugs
Metabolic (ecxema)
Genetic late onset
Intraocular disease
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8
Q

Describe developmental cataracts

A

Congenital or formed early in life, don’t usually interefere with vision (a technically opacity)

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9
Q

Name the many kinds of developmental cataracts

A 
Congenital nuclear
Anterior polayer (pyramidal)
Umbilicated
Axial fusiform
Sutural opacities
Coralliform
Persistent Hyperplastic Primary Vitreous (PHPV)
Luxated Lens
Zonula/Lamellar
Galactosemia
Spherophakia
Lenticonus
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10
Q

Describe a congenital nuclear cataracts

A

Tiny white dot
Located in the center of the lens
Formed by loose epithelical cells getting caught during lens vessicle formation
Rarely affect vision if eveer

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11
Q

Describe an anterior polar cataract (pyramidal)

A

Occurs in 4th week as lens vessicle pinches off surface ectoderm
Opacity on the front surface of lens capsule
Cataract has pyramidal shape with apex pointing out into AC
No VA effect

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12
Q

Describe an Umbilical Cataract

A

If during 4th week of development posterior epithelial cells do not become primary lens fibers then nucleus never forms, a collapse and opaque lens forms
“Umbilicated - like a red blood corpuscle”

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13
Q

Describe an Axial fusion cataract

A

Lens fibers diying while they mitigate forward

Opacity forms anterior to posterior going through many layers of the lens

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14
Q

Describe Sutural Opacities

A

Form when the lens fibers do not meet properly and cause an extra space that’s filled with an albuminoid substance

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15
Q

Describe a coralliform cataract

A

Sutural opacities with an irregular coral shape, aggregated sutural opacities that combine
May or may not affect VA

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16
Q

Describe a persistent hyperplastic primary vitreous cataract

A

Forms in the 7th month of development and avascular
Hyaloid vasculosa (primary vitreous) can persist and pervent lens growth –> small lens that’s opaque and still vascularized
Can result in leukocoria
Can see Mittendorf Dots too, reminants of PHPV on the back of the lens

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17
Q

Describe a tunica vasculosa lentis

A

Form of PHPV; unilateral and noticed in neonatal period
Associated with micropthalmos, lens may be cataractous
IOP may be high
Elongated ciliary processes are visible through dilated pupil
B-scan confirms the diagnosis in presence of a cataract

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18
Q

What is a Lens Coloboma?

A

Tertiary vitreous fail to form –> lens will be subluxated

May form due to iris coloboma or Marfan’s syndrome

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19
Q

Describe a lamellar cataract/zonular cataract

A

Due to calcium levels droping then restoring causing opacification and clearing
In young children the opacity are large and with age appears smaller as it’s pushed towards center of the lens
Can appear as spokes/riders

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20
Q

What is a Galactosemia cataract?

A

Developmental cataract, rare and bilateral condition
Caused by lack of enzymes to metabolize galactose in GI tract
Cataract is right below lens capsule
Condition may reverse if caught early enough

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21
Q

What are the two kinds of galactosemia cataracts?

A

Deficiency of Galactokinase - only involves formation of cataracts
Deficiency of Uridil Transferease - More common, mental retardation if milk continues to be ingested “failure to thrive”

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22
Q

What is spherophakia/microspherophakia

A

Congenital variant and child is born wit ha small highly convex lens that is almost spherical in shape
Results in very high myopia
May cause pupillary block, lens bulging forward and blocking the aqueous

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23
Q

What is lenticonus?

A

Lens capsule too thin and causing a cone line protrusion of the lens

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24
Q

What are the signs of lenticonus?

A

High myopia, high irregular astigmatism

May occur anteriorly or posteriorly

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25
Q

What is lentiglobus?

A

Much larger area affected but otherwise it’s lenticonus, entier posterior lens can be bulging for example

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26
Q

What is a Senescent Cataract?

A

The most common and inevitable cataract due to decrease in lens metabolism, an aggregation of proteins and Na/K atpase slows down.
Age Related

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27
Q

What are common patient complaints for senescent cataracts?

A

Smoky hazy vision

Not a sudden loss of vision, no VF loss and no pain

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28
Q

What are the three kinds of senescent cataract?

A

Cortical
Nuclear
Posterior Subcapsular

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29
Q

Describe a Cortical Cataract (Cuneiform)

A 
Varied effect on VA
Glare or monocular diplopia
Slow/rapid progression possible
Vacuoles, water clefts and spoking
Intumescent, mature
30
Q

What is the clinical presentation to a cortical cataract?

A

Water vacuoles, clefts (between lens fibers due to hydration of cortex)
Cortical spoking
Lamellar separation
Punctate dots

31
Q

Describe the progression of a cortical cataract

A

Lens metabolism decreaes via age, Na/K ATPase slows, now sodium is low and potassium is high
Cationic shift causes water to enter and lens to swell
Water enters through semi-permeable laminated capsule and comes in contact with water soluble proteins in outer cortex

32
Q

Describe the pathophysiology of the cortical cataract

A

A and B crystalline fibers dissolve forming opaque aggregates
Cortex becomes gray and white, beginning to opacify.
# of amino acids is increasing and pH of lens decreases
Cathepsins (proteolytic enzymes) activated and change the pH
Lens starts to shrink

33
Q

What are the four stages to a cortical cataract?

A

Incipient (immature)
Inturnescent (Phakomorphic/Phacogenic GLC)
Mature
Hypermature (Phakolytic)

34
Q

Describe the Incipient stage of a cortical cataract

A

First stage; see water vacuoles under lens capsule

35
Q

Describe the intumescent stage of a cortical cataract

A

Lens takes in more water, mature cataract that is swollen
Opacification of lens fibers
Lens may look fairly clear with VA only slightly affected
Lens is bigger with some spoke formation
Can lead to secondary glaucoma

36
Q

Describe the mature cortical cataract stage

A

All fibers are obaque and the lens is starting to shrink, VA starting to decrease

37
Q

Describe the hypermature cortical cataract stage

A

Continued development of mature cataract
Caused by degenerated protein leakage of the liquefied cortex out of the lens capsule
Lens is smaller than normal size and shrivelling
May lead to secondary glaucoma
Not an inflammatory condition

38
Q

What is the name for a hypermature cataract?

A

Morganian cataract; lens is completely liquefied and nucleus sinks inside the lens capsule

39
Q

Describe a posterior subcapsular cataract

A

Under posterior lens capsule and start centrally and move peripherally
Due to the normal aging process or trauma, steroids and diabetes
Can cause a profound VA loss by sitting on the nodal point of the eye, especially in high illumination

40
Q

What is a posterior subcapsular cataract called in a younger patient?

A

Cupuliform cataract

41
Q

Describe a cupuliform cataract (PSC in young patient)

A

Glare or lower VA, miosis, near > distance affected
Secondary to trauma, steroids, inflammation, Diabetes, ionizing radiation
Best seen with retroillumination

42
Q

Describe the nuclear changes in the lens

A

New fibers made at outer portion of lens, push inward and compact together into a hardened nucleus
UV radiation causes biochemical changes causing accumulation of phosphorescent chromophors and can cause nuclear sclerosis
Lens hardens, yellows with time and becomes less elastic leading to presbyopia

43
Q

Describe a nuclear cataract

A

More predictable age wise, regular progression

Variety of patient complaints and many different refractive indices in the lens now

44
Q

What are the signs for a nuclear cataract?

A

Refraction with NO end point, yellow nucleus, myopic shift “second sight”, monocular diplopia

45
Q

What are the colorations of nuclear cataracts

A

Yellowing - urochrome pigment
Brunescent - opacity is brown and usually at the advanced stage
Cataract Nigra - black colored cataract

46
Q

What are normal age-related changes in nuclear cataracts?

A

Some degree of yellowing is normal
Excessive is a nuclear cataract
Progress is slow and usually distance affected more than near
Poor hue discrimination, especially with blue
Lenticular myopia, the increase in lens refractive index, IE second sight

47
Q

Give the AOA classification of a Nuclear Cataract

A

Grade 1 - Mild
Grade 2 - Moderate
Grade 3 - Pronounced
Grade 4 - Severe

48
Q

Give the AOA classification of a Cortical Cataract

A 
% of pupillary space affected
Grade 1 - 10%
Grade 2 - 10-50%
Grade 3 - 50-90%
Grade 4 - >90%
49
Q

Give the AOA classification of Posterior Subcapsular Cataract

A 
% of capsular area
Grade 1 - 3%
Grade 2 - 30%
Grade 3 - 50%
Grade 4 - >50%
50
Q

Describe a traumatic cataract

A

Trauma causing a change in lens permeability
Imemdiate or delayed reaction (years)
Look for cataract to be unilateral
Other signs include a ruptured capsule and lens dislocation

51
Q

What are all the associated conditions with traumatic cataracts/phakoanaphylactic uveitis

A 
Vossius ring
Rosette
Exfoliation
Siderosis lentis
Chalcosis lentis
Subluxation/Luxation
52
Q

Describe a Vossius’ ring cataract

A

With trauma the lens capsule may not rupture, instead ring of iris pigment deposited on the anterior lens surface

53
Q

Describe Rosette cataract

A

A kind of cortical cataract, seen at posterior lens capsule (thinnest part of capsule)
Due to trauma, lens fibers begin to dissolve along the line of their pattern of growth

54
Q

What is Exfoliation

A

Lens capsule rupturing due to trauma
Cortical material escapes into aqueous and an opacity forms
Lens protein is now recognized by the immune system as a foreign substance causing phakoanaphylactic uveitis

55
Q

Describe Siderosis Lentis

A

Caused by an IRON foreign body penetrating the lens

Rust results underneath the capsule leading to a complete cortical cataract

56
Q

Describe Chalcosis Lentis

A

Excessive amount of COPPER in the eye
Small yellowish-brown opacities in subcapsular cortex of lens and pupillary zone with a petal-like spoke that extends towards the equater
Can cause a green to reddish brown discoloration
Shows as a Sunflower Cataract

57
Q

What can cause a Chalcosis Lentis?

A

Intraocular foreign body containg copper
Eyedrops containing copper sulfate
Wilson’s disease
Manamgent is removal of the foreign body

58
Q

What is subluxation?

A

Due to trauma, zonules rupturing allowing the lens to be pulled to one side
an INCOMPLETE lens detachment

59
Q

What is a Luxation?

A

COMPLETE detachment of the lens, may dislocate anteriorly and posteriorly
Best choice is to shift posteriorly, lay the patient back; this is to keep the TM open

60
Q

Describe the two dermatologic cataracts

A

Cortical stellate
Anterior shield like
These occur with skin conditions such as eczema (atopic dermatitis) and scleroderma

61
Q

Describe diabetic cataracts

A 
Type II (late onset) - will develop a senescent cataract earlier than normal
Type I - "Snowflake cataracts" limited to juvenile diabetics
Opacification occurs because of high sugar levels leading to high aqueous sugar levels that diffuse into the lens and is converted to alcohol creating a hypertonic environment
62
Q

Describe Retinitis Pigmentosa

A

Hereditary retinal dystrophy
Refers to group on inherited conditions involving a reduced VF and night blindness
Posterior subcapsular cataract develops in the late stage

63
Q

What kinds of cataract can occur with radiation and energy?

A

Infra-red/Glass blower’s cataract
Irradiation
Electic Shock

64
Q

Describe an Infra-red Cataract

A

“Glass blower’s cataract”
Due to a lack of eye protection
Iris absorbs heat and transfers it to the lens, you’re cooking the lens.
Lens turns white, capsule exfoliates, splits and curls up into the anterior chamber

65
Q

Describe a cataract induced by an X-ray/gamma rays

A

Seen with survivors of nuclear warfare
Develops 1-2 years after incident
Also found in cancer patients in radiation therapy
The radiation interferes with dividing cells at lens equator

66
Q

Describe an electric shock induced cataract

A

Cortical cataract due to heat, concussion of the shock and/or electrolytic dissociation

67
Q

Describe cataracts that are secondary to medication

A

Steroids cause PSC cataracts

Phenothiazines used in anti-psychotics cause stellated subcapsular cataracts (anterior/posterior)

68
Q

Describe ECCE Cataract surgery

A

Extrasubcapsular Cataract Extraction –> Removal of the lens nucleus

69
Q

Describe ICCE Cataract surgery

A

Intracapsular Cataract Extraction –> Entier lens is removed including the capsule

70
Q

Describe Phacoemulsification Cataract Surgery

A

Area of anterior lens capsule is removed and the lens is broken up and sucked out
Posterior capsule remains to support the IOL

Ocular Disease Test 2 (6 decks)

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